Soon, when people who experience migraine feel a headache coming, they may be able to whip out a fast-acting nasal spray to soften symptoms before they appear. The spray, called zavegapant, sits in phase 2/3 clinical trials, awaiting FDA approval. If it reaches the public, it’ll join a growing crowd of medicines that treat the condition. 

It turns out the scope of options for migraine treatment extends far beyond gulping twin Tylenols, squeezing your eyes closed, and hoping for the best. Among the options are oral medications, monthly injections, and an electronic device that stimulates nerves through your forehead. It looks to be stolen from the set of a space opera.

Just 30 years ago, treatment options were limited. (It wasn’t until 2014 that the FDA approved Cefaly, the nerve stimulator.) Antidepressants and anti-seizure drugs, which happened to mitigate migraine for some, were sometimes borrowed and used. But at best these meds can be "disappointing,” as Dr. Morris Levin, director of the UCSF Headache Center, puts it. “Their success rate is variable, and they are all prone to causing side effects.” 

Triptans, a class of drugs introduced specifically to treat migraine in the 1990s, showed some promise. In fact, they’re still often prescribed. “But they don’t work for all patients,” says Dr. Alina Masters-Israilov, a neurologist at Weill Cornell Medicine, citing their own host of side effects.

The mismatch of migraine—a ubiquitous condition affecting a billion people annually—and the sparse number of treatments left a huge gap. But in the 2000s, that changed. The field of headache medicine became more recognized, with the first accredited medical programs appearing in 2006. 

Another boost came when researchers determined that calcitonin gene-related peptide (CGRP), a chemical compound released by sensory nerves that engages with cells. The researchers discovered that by blocking the cell receptors that CGRP contact, they could diminish migraine pain. “We had a major breakthrough,” says Wade Cooper, director of the Headache and Neuropathic Pain Clinic at University of Michigan Health. It would form the nucleus of a new generation of migraine meds.

In the 2010s, treatments that blocked CGRP began to appear, both to prevent migraine and to address them at the onset. One class of preventative therapies, called CGRP-targeting monoclonal antibodies, helps chronic migraine sufferers in the form of a monthly shot. "These consist of injection devices that you hold over your skin, push a button, then a short little needle injects below the skin over a few seconds,” says Dr. Levin. Viola. Joining them are Gepants, an oral therapy that also marshals CGRP technology, either on a preventative basis or to take when a migraine appears. 

Accompanying CGRP-related treatments are a host of other options. There are physical devices, like Cefaly and Relivion, headgear that use electric pulses to dull nerve systems that cause migraine pain. Botox injections are another way to handle pain-causing nerves. “In theory, what we think is happening is the peripheral nerves that are around the head and neck take up the Botox,” says Dr. Masters-Israilov. “That, in turn, prevents this sort of constant pain signaling centrally into the brain.” 

Pharmacological treatments for migraine have evolved at breakneck speed over the last decade, but doctors say prescribing behavior change can show equal promise. “We often also consider modalities like acupuncture for migraine treatments,” says Dr. Masters-Israilov. “Yoga has been studied for migraine as well.”

All of this amounts to a wide suite of treatments that are beginning to match the scope of the condition. That provides great optimism to neurologists treating the condition. “It changes lives, man,” says Dr. Cooper.

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